Provider Demographics
NPI:1154513091
Name:MONTOYA, KELLY LEE (MFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:MONTOYA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 VALLEY GLEN DR APT 225
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-4863
Mailing Address - Country:US
Mailing Address - Phone:805-709-6127
Mailing Address - Fax:
Practice Address - Street 1:1550 VALLEY GLEN DR APT 225
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:CA
Practice Address - Zip Code:95620-4863
Practice Address - Country:US
Practice Address - Phone:805-709-6127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58563101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health